Study guide
22.3 Conducting and Closing a Second-Level Review
AHIMA Certified Documentation Integrity Practitioner CDIP
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1 Chapter 1: Authoritative Coding Resources & Conventions
1.1 Official Coding Resources: Scope, Authority & Research 1.2 General Coding Conventions, Punctuation & Instructional Notes 1.3 Chapter-Specific and Setting-Specific Coding Guidelines
2 Chapter 2: Principal & Secondary Diagnosis Determination
2.1 UHDDS Definitions & Principal Diagnosis Selection 2.2 Two or More Diagnoses Equally Meeting Criteria 2.3 Secondary Diagnosis Reporting Standards & POA Status
3 Chapter 3: Procedure Coding & Sequencing Standards
3.1 ICD-10-PCS Root Operations & Inpatient Procedure Coding 3.2 Principal Procedure Selection & Surgical Sequencing 3.3 Applying Official References to Ambiguous Records
4 Chapter 4: Inpatient Prospective Payment & DRG Grouping
4.1 MS-DRG Logic, CC/MCC Exclusions & Severity Levels 4.2 Working vs. Final DRG Assignment & Optimization vs. Maximization 4.3 CDI-Coding Reconciliation & Annual Regulatory Updates
5 Chapter 5: Enterprise CDI Promotion & Program Value
5.1 Articulating CDI Value to C-Suite & Hospital Leadership 5.2 Organizational Models, Inpatient/Outpatient Scope & Staffing 5.3 Cross-Functional Collaboration: HIM, Quality & Case Management
6 Chapter 6: Cross-Functional Alignment & Improvement Projects
6.1 Partnering with Nursing, Pharmacy & Allied Health Professionals 6.2 Documentation Improvement Project Identification & Scoping 6.3 Executing, Piloting & Measuring CDI Project Outcomes
7 Chapter 7: Physician Champion Engagement & Clinical Advocacy
7.1 Selection, Role & Credibility of the CDI Physician Champion 7.2 Peer-to-Peer Engagement, Coaching & Overcoming Resistance 7.3 Developing Standard CDI Operational Policies & Procedures
8 Chapter 8: Compliant Policy Architecture & Query Governance
8.1 AHIMA/ACDIS Practice Brief Standards in Policy Construction 8.2 Medical Record Integration of Provider Query Responses 8.3 Policies for Electronic, Paper, and Verbal Query Communications
9 Chapter 9: Query Escalation & Professional Communication
9.1 Chain of Command & Protocols for Unanswered Queries 9.2 Conflict Resolution & Professional Feedback Mechanisms 9.3 Assessing Stakeholder Learning Needs & Specialty Curricula
10 Chapter 10: Educational Delivery & Broader Healthcare Impacts
10.1 Delivery Methods: Microlearning, Case Studies & Grand Rounds 10.2 Documentation Impacts on Clinical Research & Epidemiology 10.3 Documentation Impacts on Case Management, LOS & Reimbursement
11 Chapter 11: Clinical Record Synthesis & Encounter Trajectory
11.1 Synthesizing Provider Notes, Consults & Progress Trajectory 11.2 Interpreting Diagnostic Imaging, Pathology & Labs 11.3 Resolving Conflicting, Ambiguous & Copy-Forward Entries
12 Chapter 12: Advanced Clinical Concepts & Review Prioritization
12.1 Pharmacotherapy, Clinical Trajectories & Disease Correlations 12.2 Inpatient Review Prioritization: High-Risk & High-Volume 12.3 Payer Prioritization, Length of Stay & Re-Review Cadence
13 Chapter 13: Clinical Indicator Mapping & Gap Recognition
13.1 Systematic Identification of Documentation Gaps 13.2 Sepsis Definitions, SEP-1, and Coding 13.3 AKI Criteria, Tubular Injury, and CKD Staging
14 Chapter 14: Diagnostic Precision in High-Impact Conditions
14.1 Respiratory Failure: Acuity, Evidence, and Sequencing 14.2 Heart Failure Phenotype, Acuity, and Hypertensive Combinations 14.3 Encephalopathy, Delirium, and Acute Cognitive Change
15 Chapter 15: Clinical Validation & Complication Discrepancies
15.1 Malnutrition Assessment, Severity, and Provider Documentation 15.2 Principles of a Compliant, Nonleading Query 15.3 Open-Ended, Multiple-Choice, and Yes/No Queries
16 Chapter 16: Query Mechanics & Direct Provider Collaboration
16.1 Electronic Query Systems, Templates, and Technology Oversight 16.2 Collaborating With the Appropriate Query Recipient 16.3 Capturing and Clarifying Query Responses
17 Chapter 17: Quality Indicators & Post-Discharge Clarification
17.1 Present on Admission Clarification and Selected HAC Rules 17.2 Clarifying Acuity, Cause, Site and Severity 17.3 Post-Discharge Query Opportunities and Limits 17.4 Managing Post-Discharge Query Workflows
18 Chapter 18: CDI Operational Dashboards & Quality Auditing
18.1 Departmental Metrics: Definitions, Calculations and Dashboard Use 18.2 Internal CDI Quality Audits and Reviewer Calibration 18.3 Query Trends: Understanding the Process and Provider Experience
19 Chapter 19: Benchmarking, Productivity & Data-Driven Workflow
19.1 Provider Documentation Benchmarking 19.2 External Benchmarking: CMI, Severity, Mortality and Length of Stay 19.3 Evaluating CDI Professional Performance 19.4 Using Data to Design CDI Workflow and Staffing
20 Chapter 20: Ethical CDI Standards & Regulatory Frameworks
20.1 Applying AHIMA Ethics to CDI Decisions 20.2 Responding to Financial Pressure and Upcoding Risks 20.3 Maintaining Competence and Professional Integrity
21 Chapter 21: Regulatory Compliance & Enforcement Landscapes
21.1 False Claims, Overpayments and Referral Laws 21.2 Regulatory Agencies, Review Contractors and Appeals 21.3 EHR Templates, Copied Text and Record Integrity
22 Chapter 22: Technology Risks & Second-Level Review Protocols
22.1 CAC, NLP and AI: Context, Oversight and Performance 22.2 Selecting Cases for Second-Level Review 22.3 Conducting and Closing a Second-Level Review
23 Chapter 23: Clinical Validation Queries & Risk Mitigation
23.1 Clinical Validation and Coding Clarification 23.2 Clinical Validation Queries and Denial Evidence 23.3 Detecting Leading, Biased and Unsupported Queries
24 Chapter 24: Noncompliant Query Remediation & Query Lifecycle Management
24.1 Query Remediation and Corrective Action 24.2 Query Timeframes, Aging and Measurement 24.3 Query Records, Retention and Evidence Preservation
22.3 Conducting and Closing a Second-Level Review
Key Takeaways Explain This Topic AI
Document the referral question, source locations, prior query activity, responsible owner and needed action; a workqueue label is not a diagnosis or disposition.
Separate clinical/documentation, reporting and downstream calculation questions before reconciling a working and final DRG.
A physician advisor can provide expertise and collegial assistance; an advisor without direct clinical care in the encounter cannot establish its diagnosis by answering a query.
Address defective drafts, delivered unanswered queries and answered queries according to their actual state. A private invalid flag does not amend the health record.
Define cohort, unit and denominator for review metrics. Targeted-sample defect rates and observed claim outcomes do not establish national benchmarks or proven denial avoidance.
Last updated: October 2026
Conducting and Closing a Second-Level Review
A second-level review should produce a supported disposition of a defined question. A workqueue label, senior job title or agreement between departments cannot substitute for the clinical record or applicable reporting rules. Design the process so the reviewer can explain what was examined, what remains uncertain, who must act and how the result was verified.
The sequence below is an example for local workflow design. It can be adapted for concurrent, pre-bill or retrospective work. An automated queue, particular conference schedule or four-pathway structure is not a universal requirement. AHIMA Clinical Validation, 2023 Update ; 2026 query guidance, Section XIII
Start with a useful referral
Record the encounter, specific concern, relevant locations and timeline, prior query activity and the action requested. State the uncertainty neutrally. “Please evaluate conflicting documentation about this condition” is more useful than “save the MCC.” Include an appropriate owner and due date under local policy, with access limited to authorized participants.
Distinguish the referral from a provider-facing query. A referral asks another reviewer to evaluate the issue; a query asks the appropriate provider to clarify documentation. The review can determine that no provider query is needed because the record or applicable coding instruction already resolves the question.
Review the record and rules independently
Read the relevant course rather than only the referring specialist's summary. Compare the provider's assessments with dated observations, treatment, monitoring, consultations and subsequent documentation. Include evidence that challenges as well as supports the concern. Determine whether information comes from this encounter, a prior encounter or a copied entry.
Separate three questions:
Clinical/documentation question: What diagnosis or course did the responsible provider document, and does an unresolved conflict or support concern need clarification?
Reporting question: What do the applicable coding conventions and guidelines require, including setting and additional-diagnosis criteria?
Downstream question: Given the final supported reporting, what does the relevant grouper or quality specification calculate?
A medication, procedure or laboratory value contributes context; it is not a universal diagnostic test. Likewise, failure to find a particular treatment does not automatically make a diagnosis invalid. Inpatient additional-diagnosis reporting can be supported by clinical evaluation, treatment, diagnostic procedures, extended stay or increased nursing care/monitoring under the applicable guideline. FY2027 ICD-10-CM guidelines, Sections I.A.19 and III
Assign the right decisions to the right people
Participant Appropriate contribution Limit
Second-level CDI reviewer Evaluate the concern, query compliance and documentation needs; record the rationale Does not independently establish or erase a provider's diagnosis
Coding professional or coding leader Apply classification conventions, guidelines and reporting requirements Does not replace the provider's diagnosis with a diagnosis inferred from clinical thresholds
Physician advisor Provide expertise, education, process review and appropriate collegial communication An administrative title alone does not authorize a diagnostic query response
Provider involved in care Clarify the clinical assessment and documentation within the provider's responsibilities Must exercise independent judgment rather than supply a requested payment result
Quality, compliance, HIM or appeals staff Address their respective measure, compliance, amendment or appeal responsibilities Their involvement does not turn an internal disposition into a binding external ruling
The 2026 query brief directs diagnostic queries to providers who provided direct clinical assessment and care in the encounter. An advisor who did not participate in that care cannot establish the encounter diagnosis by answering a query after administrative chart review. When documentation conflicts, the attending provider as defined by policy should clarify the discrepancy. Advisor coaching and peer discussion can help that process without replacing the responsible provider. 2026 query guidance, Section VII
Worked conflict: The attending documents encephalopathy while a consultant explicitly rules it out. An unsent query asks the attending to confirm encephalopathy “as an MCC.” Replace that draft with an appropriate neutral clarification that accurately presents the conflict and relevant evidence. Use the attending route specified by policy; seek advisor assistance if useful. Preserve both original notes. The goal is an accurate clinical statement, not a forced consensus that protects reimbursement.
Select and document a supported disposition
Possible outcomes include:
No further clarification needed: Identify the existing documentation and rule that resolve the referral.
Clarification needed: Send a compliant query to an appropriate recipient and track the response under policy.
Reporting correction needed: Route the supported correction to the authorized coding or reporting owner and verify it.
Query defect found: Address the draft, delivered query and any existing response through the appropriate process.
Concern remains unresolved: Record the issue and escalate to the designated clinical, coding, compliance or medical-staff authority according to its nature.
These are useful disposition categories, not a nationally mandated list. “Reviewed” is insufficient if it leaves the actual question unanswered. Record the reason for the decision and the next owner, including when the correct result is no change.
Handle a defective query without rewriting the record
An inappropriate unsent draft can be corrected before delivery. A delivered but unanswered query can require withdrawal or other action under policy. An answered query is different: do not simply mark its clinical response “invalid” in a private workqueue and treat that as an amendment to the health record. Evaluate the defect and clinical documentation separately; involve the responsible provider and HIM's amendment process when appropriate. Preserve the relevant history and required records. Section 24.1 develops remediation in more detail. 2026 query guidance, Sections XIII and V
If a response does not support the reviewer's preferred diagnosis, a second reviewer should not repeat the same question merely to override that judgment. A subsequent query may be appropriate for new or evolving information or genuinely needed specificity. Apply the brief's intent-and-pattern standard and the organization's closure process. 2026 query guidance, Section IX
Reconcile a DRG difference by explaining its cause
A working DRG may differ from the final result because information, diagnoses, procedures or grouping inputs changed. It may also reveal an error. Compare the actual inputs and applicable rules before assuming a conflict between departments. A scheduled conference is one possible method; direct documented discussion may suffice under local policy.
For example, the working abstract includes a secondary diagnosis that the final abstract omits. Determine whether the issue is documentation, a reporting criterion, a code assignment or the grouper configuration. Seek provider clarification for a clinical documentation problem and apply the appropriate coding process for a coding error. A physician advisor or finance leader cannot resolve the matter by selecting the higher-paying DRG. Recalculate downstream results only after the supported reporting decision.
Verify closure and use the findings
Confirm that the provider response is authenticated and incorporated through the approved record process where applicable, the coding/reporting owner completed any required action and the referral disposition matches the result. Address the actual remaining concern before release or further processing under the organization's authorized workflow. An internal review cannot guarantee that a payer will accept the claim or that a later appeal will succeed.
Use metrics that describe the work actually performed. Define the eligible population, unit, numerator, denominator and time window. Completed referrals, time to resolution, documented query defects, unresolved issues and recurrence after intervention can each answer different questions. A high agreement rate does not establish accurate review, and a high exclusion rate is not the purpose of reviewing quality flags.
Worked feedback: In a targeted review of 30 malnutrition queries, reviewers identify 6 with a defined construction defect. The defect proportion in that reviewed group is 6/30 = 20%. It is not automatically the rate for all queries or proof that novice staff caused the problem. Examine the cases, template design, indicator sourcing and review conditions. Provide specific education or tool correction, assign an owner and recheck appropriate later work. Track reporting increases, decreases and no-change outcomes as accuracy results; do not reward a preferred financial direction. AHIMA clinical-validation education guidance ; 2026 query governance and auditing guidance
Finally, distinguish observed outcomes from estimates. A claim not yet denied does not prove that review prevented a denial. Report the cohort, follow-up period and limitations of any financial or denial analysis. The review program improves through verified corrections and reduced recurrence, not an invented national agreement, retraction or denial-avoidance target.